PacificSource Medicare Essentials Choice Rx 14 (HMO-POS) Formulary



Below is the 2022 Formulary, or prescription drug list, from Pacificsource Community Health Plans for PacificSource Medicare Essentials Choice Rx 14 (HMO-POS)( H3864-014). A formulary is a list of prescription medications that are covered under Pacificsource Community Health Plans's 2022 Medicare Advantage Plan in Oregon.

This PacificSource Medicare Essentials Choice Rx 14 (HMO-POS) plan has a $0 drug deductible.

The Initial Coverage Limit (ICL) for this plan is $4430. The Initial Coverage Period is the period after the Deductible has been met but before the Coverage Gap phase. Once you and your plan provider have spent $4430 on covered drugs. (combined amount plus your deductible)

You will enter the coverage gap. (AKA "donut hole") Once you reach the coverage gap you will be required to pay 25% of the plan's cost for covered brand-name prescription drugs unless your plan offers additional coverage. You can see if this plan offers coverage in the "donut hole" be clicking the "Coverage Gap" link on the left above the chart.

In 2022 if you have spent $7550 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. PacificSource Medicare Essentials Choice Rx 14 (HMO-POS) will begin paying approximately 95% of your covered medication expenses. You can see if this plan covers your drugs in the Catastrophic Phase by clicking the "Catastrophic" link on the left above the chart.




Plan Name:PacificSource Medicare Essentials Choice Rx 14 (HMO-POS)
Plan ID: H3864-014
Formulary
Provider: Pacificsource Community Health Plans
Plan Year:2022
Premium:$40.00
Deductible:$0
Initial Coverage Limit:$4430
Coverage Area:Oregon


Change Table Options:

Drugs Starting Letter:
Coverage Phase:

⇅ Click the Header to Sort
Drug
Name⇅
Tier
Level
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Bacitracin Zinc And Polymyxin B Sulfate
2$12$17$12NN
Baclofen
2$12$17$12NN
Balsalazide Disodium
2$12$17$12NN
Balversa
533%33%33%YN
Balziva
2$12$17$12NN
Baraclude
3$37$47$37NN
Bcg Vaccine
3$37$47$37NN
Benazepril Hydrochloride And Hydrochlorothiazide
6$0$0$0NN
Benznidazole
3$37$47$37NN
Benztropine Mesylate
1$3$8$0NN
Bepotastine Besilate
2$12$17$12NN
Berinert
533%33%33%YN
Betamethasone Dipropionate
2$12$17$12NN
Betamethasone Valerate
2$12$17$12NN
Betaxolol Hydrochloride
2$12$17$12NN
Bethanechol Chloride
2$12$17$12NN
Betoptic S
3$37$47$37NN
Bexarotene
533%33%33%YN
Bexsero
3$37$47$37NN
Bicillin C-r 900/300
431%33%31%NN
Bicillin Cr
431%33%31%NN
Bicillin L-a
431%33%31%NN
Biktarvy
533%33%33%30/30NN
Bisoprolol Fumarate
2$12$17$12NN
Bisoprolol Fumarate And Hydrochlorothiazide
2$12$17$12NN
Blephamide
431%33%31%NN
Blisovi 24 Fe
2$12$17$12NN
Blisovi Fe 1.5/30
2$12$17$12NN
Boostrix
3$37$47$37NN
Bosulif
533%33%33%30/30YN
Braftovi
533%33%33%YN
Breo Ellipta
3$37$47$37NN
Briellyn
2$12$17$12NN
Brilinta
3$37$47$37NN
Brimonidine Tartrate
2$12$17$12NN
Briviact
533%33%33%NY
Bromfenac Ophthalmic Solution 0.09%
2$12$17$12NN
Budesonide
431%33%31%NN
Budesonide And Formoterol Fumarate Dihydrate
2$12$17$12NN
Bumetanide
2$12$17$12NN
Buprenorphine
431%33%31%4/28NN
Buprenorphine And Naloxone
2$12$17$1260/30NN
Buprenorphine Hcl
2$12$17$1290/30NN
Buprenorphine Hydrochloride And Naloxone Hydrochlo
2$12$17$1290/30NN
Bupropion Hydrochloride
2$12$17$12NN
Buspirone Hydrochloride
2$12$17$12NN
Butorphanol Tartrate
2$12$17$12/30NN
Bydureon Bcise
3$37$47$374/28NN
Byetta
431%33%31%NN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H3864-014

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1.Pre-Deductable: Before you reach the plans deductible of $0. Some plans offer select Pre-deductible drug Coverage
2.Initial Coverage: (ICL) After you reach the plans deductible but before the Initial Coverage limit of $4430
3.Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $7550 in 2022.
4.Catastrophic: Anything over $7550 you will receive a significant increase in coverage.

Definitions:

Premium: A monthly flat fee that varies by plan.
Deductible: The amount you must pay each year for your prescriptions before your plan begins to pay its share of your covered drugs. The max in 2022 is $320. Some plans have a $0 Deductible.
Tier Level: Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less.
Quantity Limit Amount/Days: Certain drugs have a Quantity Limit. That means the plan will only cover the drug up to a designated quantity or amount. If your prescribing doctor feels it is necessary to exceed the set limit, he or she must get prior approval before the higher quantity will be covered.
Prior Authorization: Certain Drugs require you or your doctor to get prior authorization in order to be covered. Usually just an additional form. If you dont get approval, the plan may not cover the drug.
Does the Deduct Apply: Some drugs do not require that the deductible is met before you receive coverage.
Step Therapy: Means you must first try one drug to treat your medical condition before the plan will cover another drug for the same condition. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Cost Preferred: Your Cost for the Drug at the Providers In Network Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non Preferred: Your Cost for the Prescription Drug at a Non-Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Mail: Your Cost for Prescription Drugs through a Mail Order Pharmacy. As a Percent of the total drug cost or a flat rate.


What if a drug I need is not listed?

Please check the formulary for different brand and generic names. If you still cannot locate your drugs, your plan may not offer coverage. Talk to your doctor first about changing your prescription to a drug on your plans formulary. If this is not an option, you can request an exception to have the plan review its coverage decision based on your individual circumstances.

Source:CMS Formulary Data Q1 2022
Source:NDC Directory by FDA.gov

**We make every attempt to keep our information accurate. But please check with the plan providers to verify all information.

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